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Thursday, March 07, 2013

Some reporting by Bloomberg provides more evidence about what happens when direct care of the most vulnerable patients is commercialized. The vulnerable patients in this case were narcotic addicts.

By way of introduction, one method of treating narcotic addiction is the use of methadone. Methadone is a narcotic that may block the "high" produced by other narcotics and thus may lead to the abuse of these drugs. Because methadone is long-acting and can be given orally in liquid form, methadone clinics traditionally provided patients one dose a day which they swallowed on the spot. The methadone would presumably block their craving for other narcotics for that day, and the method of administration would prevent diversion of the drug. Methadone clinics became more prevalent starting in the 1960s, and like most "health care provider organizations," as we now call them, were then largely non-profit.

On a personal note, in the 1980s, I was the internal medicine physician for a non-profit hospital based methadone clinic designed for patients who had become addicted to prescription narcotics. It was a challenging task, but the challenges seemed manageable. That was then.

Nowadays, methadone clinics are more likely to be for-profit. In this brave new world of for-profit "health care delivery," there may be problems unlike those seen "back in the day." For example, Bloomberg just reported on a case with a distinctly colorful title

Dead Man Spurs Methadone Probe at Bain’s CRC Clinic in Baltimore

Maryland state regulators are
investigating an addiction-treatment clinic owned by Bain
Capital Partners LLC after the methadone-related death of a
Baltimore man.

The probe is focused on the Pine Heights Treatment Center
in Baltimore, one of dozens of clinics operated by Bain’s CRC
Health Corp., the largest methadone-treatment provider in the
U.S. It was triggered by a complaint from the public, said Dori
Henry, a spokeswoman for the state Alcohol and Drug Abuse
Administration. She declined to comment on the investigation’s
details.

The complaint alleges that Warren Lumpkin, 34, a forklift
operator, died on Jan. 4 after ingesting methadone that was
given to him by a CRC patient, according to a copy obtained by
Bloomberg News. An autopsy found that 'methadone intoxication'
contributed to his death, records show.

Lumpkin’s ex-wife, Sabrina M. Lumpkin, who filed the
complaint, said in it that he wasn’t a patient at the CRC
clinic. He had a friend who was, and that friend gave half a
dose of methadone from the clinic to Lumpkin, according to the
complaint.

Note that "back in the day," such an event would have been nearly impossible. As noted above, patients were given a cup of liquid containing their daily methadone dose, and drank it under observation. Practically, they could not "cheek" or otherwise divert the drug. Of course, that approach required personnel to observe each patient each day. Paying those personnel made the operation more expensive. "Back in the day," though, non-profit hospitals and clinics were willing to provide the service in the interest of making sure the patients, and only the patients got the prescribed treatment.

Things may be different when methadone clinics are run for a profit. A Bloomberg investigative report published in February looked into the operations of the company that owned the clinic in Maryland. That too had a provocative title and started with a similarly disconcerting case.

Drug Users Turn Death Dealers as Methadone From Bain Hits Street

After Jennifer Vanlieu turned to methadone treatment to beat an
addiction to heroin and pain pills, she morphed from drug user to
convicted drug dealer.

Vanlieu said she got a carryout methadone dose at a clinic operated
by CRC Health Corp. in Richmond, Indiana, in March, 2010, and then gave
about 15 milligrams to her friend Carissa Plemons. Plemons died hours
later, after ingesting a lethal mix of methadone and other drugs,
according to police reports.

Take-home methadone -- doses
patients carry out instead of taking at clinics -- enabled the abuse,
said Vanlieu, 26, who was sentenced to six years in prison for dealing
the drug to Plemons. While she didn’t sell it to her friend, she said in
an interview that other clinic patients often resold their take- homes.
CRC is owned by Boston-based Bain Capital Partners LLC and is the
largest U.S. provider of methadone treatment.

'Some would sell it in the parking lot,' she said.

As in the first case, unlike the process "back in the day," now patients, who are almost all presumably narcotic addicts, may be given multiple doses of liquid methadone to take home. They are no longer required to take a daily dose of methadone under observation. As the case above illustrates, it is all too easy to divert take home doses of methadone. While methadone can be used to block the effects of other narcotics, it can also be abused. Obviously, as in the cases above, abused methadone can cause a lethal overdose.

Wide Use of Take-Home Methadone

The Bloomberg report found multiple instances in which CRC Health clinics handed out multiple take-home methadone doses apparently without proper consideration of the risk or supervision of the patients.

In states where CRC has had its highest patient counts -- Indiana, West
Virginia, California and Oregon -- available data and interviews show
the company tries to provide take-home packages, which range from one
dose to as many as 30, more often than other clinics.

In addition,

The Richmond, Indiana, clinic gave take-home methadone to a patient
who flunked a drug test, a January 2012 audit found. The company’s
Williamson, West Virginia, clinic didn’t immediately revoke take-homes
from a patient who had two positive drug tests in 2010, records show. In
2011, inspectors found no evidence that a physician at CRC’s clinic in
Renton, Washington, used 'good clinical, judgment' in giving patients
carryout doses.

A CRC center in Chattanooga, Tennessee, failed to
supervise take-home doses properly in a case 'clearly indicative of
drug diversion,' state authorities found in June 2011. The company’s
clinics in Claymont, Delaware, and Coatesville, Pennsylvania, were
faulted in May 2012 and October 2010, respectively, for giving
carry-outs to patients who missed required counseling, records show.

As
for the spot-checks Herschman described -- they hardly ever happened at
CRC’s clinic in Goldsboro, North Carolina, said Liaudaitis, the former
counselor.

Furthermore,

In Indiana, CRC’s five clinics served 69 percent of methadone patients
in 2011, while distributing 96 percent of the take-homes tracked by
state records. Patients of CRC’s dozen California clinics received
carryout packages of as many as 30 doses at a rate twice that of all
others. In Virginia, 74 percent of patients at CRC’s three clinics got
at least one take-home dose a week in August 2012, while 47 percent of
patients at all other clinics did, state records show.

The Business Model Behind Take-Home Methadone

So why would a methadone clinic hand multiple doses of an abusable narcotic to narcotic abusers? The Bloomberg article went on to document some possible reasons which ultimately have to do with the business model of for-profit methadone clinics.

First of all, providing multiple doses of methadone requires less time from clinic personnel, which is handy when the clinics may be under-staffed by over-worked poorly paid personnel.

'That was the culture -- keep the census up,' said Mike Liaudaitis, who
worked as a counselor at CRC’s clinic in Goldsboro, North Carolina, from
mid-2009 until early 2011. He recalls being swamped with a 64-person
caseload that exceeded the state’s limit of 50.

Also,

'Clearly the company is saving money if they’re distributing multiple take-home doses at one time,' said West Virginia Delegate Don Perdue,
a Democrat who has pursued stricter oversight of for-profit clinics. 'They don’t have to have as many staff handing out the merchandise.'

In particular,

the Goldsboro clinic -- like others described by regulators and
former CRC employees in Indiana and West Virginia -- was frequently
understaffed, Liaudaitis said.

Since Jan. 1, 2009, CRC’s clinics
haven’t met staffing standards more than 50 times, regulatory records
from 15 states show. Clinics were cited 80 times for failing to document
that they gave patients enough counseling. In response, the company
agreed to hire more, recruit more aggressively and increase supervision.
Competition for qualified workers is intense, CRC said in its 2011
annual report.

CRC didn’t pay well enough to attract or keep
experienced counselors, said Malaysia Williams, who worked at its clinic
in Huntington, West Virginia, from June 2009 through March 2010. 'Nobody stayed there,' she said. 'It paid poorly.'

Williams got $13 an hour, she said -- about the same amount other former counselors reported. That’s roughly $27,000 a year.

There is evidence that under-staffing, under-payment of personnel, and the wide use of take-home methadone lead to big increases in short-term revenue for CRC Health, the for-profit corporation running the clinics.

Until recently, there was little difference between the operations of
for-profit and non-profit methadone clinics, said Thomas D’Aunno, a
professor of health policy and management at Columbia University who has
tracked the treatment centers for years. That changed in 2011 survey
data, which showed 'significant differences,' he said: For-profit
clinics had fewer staffers than public clinics.

As Williams struggled to catch up in Huntington, the clinic pushed its
revenue up almost 8 percent to $5 million in 2010 -- while expenses
increased less than 1 percent to $2.6 million, according to state
regulatory documents.

Private Equity's Take Over of Methadone Clinics

The potential for big revenues has drawn private equity into the world of methadone maintenance for the treatment of narcotic addiction.

Nurtured by government spending, methadone clinics spread nationwide
in the 1960s and ’70s until strapped state and local governments began
decreasing their outlays. By 2010, for-profit providers controlled 52.8
percent of the 1,200 U.S. clinics.

Over the past seven years,
private equity firms have invested more than $2.2 billion in
substance-abuse treatment and behavioral health companies in 62 deals,
according to PitchBook Data Inc., a Seattle-based research firm.

Addiction-treatment
companies are 'some of the most sought-after -- and valuable --
acquisition candidates in health care,' partly because of profit margins
that can top 20 percent, according to the Braff Group, a
Pittsburgh-based mergers and acquisitions advisory firm.

As it turns out, CRC Health was acquired by one of the more notable private equity firms.

Bain Capital, the private equity firm co-founded by former Republican presidential candidate Mitt Romney,
paid $723 million for CRC in 2006, corporate filings show. Romney, who
left Bain in 1999, had no input in its investments or management of
companies after that, he has said.

Still, Romney reported last
year that he owned more than $1 million worth of a Bain fund that holds
most of CRC’s shares. He reported receiving between $100,000 and $1
million in dividends, interest and capital gains from that holding, as
well as income from two other Bain funds with interests in CRC,
according to the financial disclosure he filed with the U.S. Office of
Government Ethics in June. Bain executives declined to comment, said Alex Stanton, a spokesman. Representatives for Romney didn’t respond to requests for comment.

CRC has reported paying Bain about $15.4 million in management fees
along with $7.2 million in fees related to the merger since 2006. The
company’s revenue more than doubled to $446 million in 2011 from $209
million in 2005. Methadone clinics generated more than a quarter of the
2011 revenue, $123 million.

Note that last year, when Mr Romney was running for the US Presidency, and hence his ties to Bain Capital were particularly newsworthy, several investigative reports about care at Bain owned health care provider organizations were published. We posted about issues at another CRC Health operation, Aspen, which operates in -patient treatment centers for psychiatric patients. Investigative reporting about that part of CRC Health also suggested that the company was putting short-term revenue ahead of patient welfare. We also posted about issues at HCA, a for-profit hospital chain partially owned by Bain, which again suggested revenue came before patients.

In one sense, this should be no surprise, since the business model for private equity is all about extracting the most money in the shortest time for acquired corporations. (Look here for more details.)

Summary

We now have more evidence that patients "cared for" directly by for-profit corporations, especially those owned by private equity firms, do not do well. Meanwhile, the top executives of these firms do exceedingly well.

We have noted
how health care organizations have increasingly been "financialized,"
lead by executives who put short-term revenue generation ahead of all
other goals, including good patient care. Furthermore, hospitals are
increasingly likely to be formally for-profit, and hence likely to be
lead by such executives. Worse, hospitals are increasingly likely to be
owned by private equity firms, further increasing the emphasis on short-term money making. Even worse, physicians are now more frequently employed by such organizations,
which may pressure them to do what it takes to increase revenue, no
matter what the effect on patients' and the public's health.

The probably effects on the quality of care, access, and costs are obvious.

In my humble opinion, before the health care bubble bursts, we need to
challenge the notion that direct health care should ever be provided, or
that medicine ought to be practiced by for-profit corporations. Before
market fundamentalism became so prominent, many states prohibited the
corporate practice of medicine, and the American Medical Association forbade the commercialization of medicine.

It is time to heed that wisdom. I submit that we will not be able to
have good quality, accessible health care at an affordable price until
we restore physicians as independent, ethical health care professionals,
and until we restore small, independent, community responsible,
non-profit hospitals as the locus for inpatient care.

True health care reform will require an end to market fundamentalism in health care.

Thanks for this truthful article! It made my day!! My son who had not touched drugs in over a year had a famous tattoo artist appt who gave him a discount if he could sit in the chair for 6 hours. After his 3rd painful appt he was convinced to take pain medicine for the tattoo appt. A methadone patient had pills. He told my son he could take these pills for pain & gave him a weeks worth of time released wafers with no instructions. My son took these pills and died in his sleep.... Ok now a week later the same methadone patient calls my son's cell and his twin answers. He asked for my son and my other son said he died after he took the methadone, he then said sorry to hear that, do you know anyone that would like these pills? These are the same type of people that sold their blood to the blood banks in the 80's when the AIDS virus came about. They lied to us then and countless lives were lost and they lie to us now. It was proven that we could not trust them they still sold their blood even though they knew it would kill people so now we are giving them dangerous pills and asking them to act responsibly? Come on! And they cloud the truth because of money, the pharmaceutical companies are making BILLIONS OFF OF METHADONE. and use the methadone patients are stool pigeons, it saves lives, yea right methadone is killing FAR FAR FAR more than heroin!!! Look at the statistics.. This drug needs to be safely dispensed like it was in the 60s, 70s, 80s, and 90s!!! Corporate greed and our loved ones are paying the price!!! Money over people!! And I dare anyone out there who says serves them right, young people have a sense of invincibleness think back when you were very young and look now and say "what was I thinking!" Too many good kids are dying because the methadone clinics are focused on profit and make it too easy for the methadone patients to take him pills (wafers, they call them it is a square pill, the term is used to confuse people!) Say no to methadone clinics in your area!!! No!!! It is PROVEN as soon as the methadone clinics open the body bags start piling up at the methadone clinics, and one pill can kill! They cannot even give a safe dosage the pill reacts differently to each patient. What is therapeutic dose for one patient is lethal for another. Methadone is the biggest reason for the drug overdose epidemic over 33 percent of all overdoses are methadone related!! And most of these promethadone comments are coming from a online forum that is overseen by moderaters that are paid by guess who? The pharmaceutical company that manufactures methadone of course!

Just to add another story about take home methadone. Two users in Duluth, Mn last fall drove to their clinic, picked up their methadone, snorted it while driving and drove in to and killed two construction workers.

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